Neonatal Abstinence Syndrome: Transforming Care for Newborns and Their Families

If there’s a success story to be told at this point in the history of the opioid crisis, it’s in the newborn intensive care unit. From changing attitudes to standardizing treatment, clinical care for infants with neonatal abstinence syndrome (NAS) and their families is markedly different than it was 10 years ago.

CHANGING ATTITUDES AND CONFRONTING BIAS

“The way we view addiction in pregnancy has changed rather dramatically over time. We, as a society and in health care, tried to punish away drug-addicted pregnancy. We called it child abuse and punished the mothers severely,” says Edward Shepherd, MD, section chief of Neonatology at Nationwide Children’s Hospital. “This is a recipe for noncompliance with the medical system. It results in parents having no interest in being part of the medical system.”

If moms feel judged by the medical system, they may delay coming to hospitals for care for themselves or their children. This results in more emergency care for big problems that regular care from a medical provider can prevent. That can be costly, both financially and in patient quality of life.

Dr. Shepherd and his team now offer care on the principle of partnership, not punishment. “One of our first goals was to figure out how to partner with parents to achieve what we want: healthy children and healthy families. At the end of the day, that’s what everyone wants. We have the same goal,” he says. “As long as it is safe to do so, we want to keep families intact.”

Part of reaching that goal is to build a relationship of trust with parents and families. The NICU team builds trust with families by using nonjudgmental terminology, involving parents in the care of the infant as much as possible and offering social work consultations and follow-up care. Many mothers with addiction have a background of abuse and trauma. As part of the culture shift, trauma-informed training for nurses supported a better understanding of how to interact with families.

“If you just sit with these moms, it’s really eye-opening,” says Dr. Reber. “Opioid addiction affects people from all walks of life, but some of these mothers have lived through horrible things. They can’t beat the cycle without a lot of help and support.”

Not every baby with NAS is born to a mother in the throes of active addiction. A baby born to a mother who is using an opiate under the supervision of a physician, perhaps for an illness or injury or as part of a medication-assisted treatment regimen, can have NAS.

There is a notion that a parent is a bad parent if their child has this disease. Dr. Shepherd and his team are trying to get away from this idea by reducing the stigma of the NAS diagnosis.

“If there’s one thing you learn in the NICU, it’s that you can’t always predict who the good parents are. There’s no way to know if a person who is abusing drugs is going to be a good parent. Unfortunately, we all know that there are perfectly healthy people who are not good parents,” says Dr. Shepherd. “There’s a lot more to substance abuse than a character flaw.”

"There's a lot more to substance abuse than a character flaw." – Edward Shepherd, MD

STREAMLINING CARE TO REDUCE LENGTH OF STAY

In 2009, Erin Keels, DNP, APRN, NNP-BC, director of Advanced Practice in Neonatology at Nationwide Children’s, was rounding with teams at each of the hospital’s seven NICU sites when it became clear that everyone was struggling with the volume and complexity of babies who were withdrawing.

“In hindsight, we can see it was creeping up on us, but it really felt like that year we reached a tipping point,” she says. “In one of our off-site NICUs, 50 percent of patients had NAS. We were running out of space for preemies because of all of the babies with NAS and their long lengths of stay.”

Around the same time, Richard McClead, Jr. MD, MHA, associate chief medical officer at Nationwide Children’s, began investigating why some of the NICUs in the network were experiencing long average lengths of stay. What he found was a dramatic increase in the number of babies with NAS and a lack of consistency in how they were treated.

“The staff in the NICUs knew this was a problem, but the rest of us didn’t until we did the deep dive in the data. These infants were having long, expensive hospital stays because of NAS,” says Dr. McClead.

“When we started looking closely at the problem, we found that we were not as good at assessing and managing the care for these infants as we thought. There was a lot of practice variability from location to location and even doctor to doctor. We also found that we had not adequately prepared and supported our staff for the challenges associated with caring for babies with NAS and their families,” adds Dr. Keels.

Together – Dr. Keels from the nursing and staffing side and Dr. McClead from the administrative and quality improvement side – they created an NAS Taskforce with key stakeholders in the NAS care path. They knew they had a big problem to solve, and according to Dr. Keels, they took the first year to learn as much as they could about NAS.

Through a series of speakers and training sessions, the neonatology team began to learn about every aspect of NAS. They heard from obstetricians on the prenatal side. They learned how to interact with families in a nonjudgmental way. And they learned how to assess the baby using the Finnegan score – the widely accepted standard for monitoring withdrawal symptoms in infants.

SCORING SYMPTOMS TO MANAGE MEDICATION

The Finnegan scale was developed in the 1960s to assess babies who were exposed to methadone in utero who were born otherwise healthy and at term.

“In our NICUs, an opioid-exposed baby may also be preterm, late-preterm or have another problem that needs addressed. And frankly, the combinations, quantities and types of drug exposures these babies are experiencing in utero are quite a bit different from methadone and heroin of the 1970s. The Finnegan scale doesn’t account for that,” says Dr. Keels. “Also, the Finnegan scale was designed to look at the first 28 days after birth. We’re often assessing babies much longer than that.”

These considerations have led the team at Nationwide Children’s to modify the Finnegan to develop a chronic assessment scale for older babies. However, it is still cumbersome and time consuming, requiring regular training, retraining and dual scoring to ensure competency.

This is an added burden for the nurses, who are essential to the care of babies with NAS. The nurses’ assessments drive the provider’s orders for medication in the weaning protocols.

According to Dr. Keels and Barry Halpern, MD, a neonatologist affiliated with many central Ohio hospitals, including Nationwide Children’s, the field may be moving further away from the Finnegan scale in favor of an “Eat, Sleep, Console” assessment. The idea behind it is this: Is the baby eating? Is the baby sleeping? Can the baby be consoled within a period of time? Drs. Keels and Halpern also add that ensuring that the baby is maintaining or gaining weight is another helpful measure in conjunction with Eat, Sleep, Console. If yes to all four, then maybe you don’t need medication, or need less medication.

In Dr. Halpern’s experience, the Finnegan scoring process can be alienating and adversarial for new moms of babies with NAS, who may already be feeling stigmatized.

“This is a critical period of involvement and bonding for the mom and baby. By assessing them with the Eat, Sleep, Console, Weight method, we can do the assessment in partnership with the mom, on the baby’s schedule. Not on the Finnegan schedule or the nurses’ schedules,” he says.

This approach also ties closely to the philosophy that perhaps it is okay if a baby with NAS is a little upset or jittery for a period of time, as long as they are eating, sleeping, consolable and gaining weight. This philosophy results in further reducing drug exposures by significantly limiting the amount of medication used in the weaning process.

In addition to limiting the amounts of morphine and methadone used in weaning protocols, experts in the field are considering another medication – buprenorphine. The drug, also known by the brand name Suboxone®, is widely used in medication-assisted treatment for adolescents and adults with addiction. Could it be better for babies with NAS?

“There’s certainly a need for more research in this area,” says Dr. Keels. “We don’t know exactly how these options impact the baby long term. And it’s something we hope to figure out over time.”

Crying, shaking and inability to sleep are among the symptoms of NAS. Nurses and physicians assess the baby’s ability to be consoled to help determine if a weaning medication is needed to relieve symptoms.

EARLY IMPROVEMENTS AND A GROWING COLLABORATIVE

“We saw that as soon as we started paying attention to the problem, it started to improve. The speakers and trainings were having an effect as we started to put into practice what we were learning. By the end of the first year, we had reduced the average length of stay from 58 to 29 days,” Dr. Keels says.

At the end of the first year, the taskforce came up with as many evidence-based guidelines as they could to develop a NAS protocol. The essential part of that plan was the weaning protocol.

“One of the best things we ever did was come up with a protocol and stick with it,” Dr. Keels says.

In fact, they would eventually find that what drug you use to wean these babies doesn’t matter so much as following a plan. In a study conducted as part of the Ohio Perinatal Quality Collaborative (OPQC), the taskforce found that hospitals without a weaning protocol had a much longer length of stay compared to hospitals using either methadone or morphine protocols. Once they added a set practice, using methadone or morphine, the lengths of stay went down.

“Close collaboration with the clinical pharmacist was essential to our success in implementing the protocol,” adds Dr. McClead.

In addition to guidelines for pharmacologic care, the taskforce, and later the OPQC, developed a toolbox of nonpharmacologic methods for treating babies with NAS and their families. Nonpharmacologic treatments include breastfeeding, skin-to-skin contact, quiet environments, dim lighting and nonbiased treatment.

“We know that breastfeeding is safe when the mother is on maintenance medication, and it’s helpful for the baby. However, only about 25 percent of mothers of babies with NAS breastfeed, according to 2017 OPQC data,” says Dr. Keels. “We’d like to see these rates improve, but in the absence of breastfeeding, feeding babies with NAS a high caloric density formula improves withdrawal symptoms compared to feeding regular formula.”

These nonpharmacologic treatments may seem like small changes, but together they make a big difference in the outcomes of the babies. In fact, some babies may not need pharmacologic treatment at all.

“It’s ultimately a balancing act. We need to make sure that the baby gets enough hospital care but not so much that it increases hardship for the family,” says Dr. Keels. “Right now, our average length of stay is about 17 days throughout the service line. And we think that’s as low as we can go with the current care models and medications we use. For future improvements, we’re really going to have to think outside the box.”

"While we've reduced the length of stay, and hospital, insurance and government policies have been put into place to reduce the number of prescription opioids 'out there,' we aren't seeing a reduction in patients with NAS." – Erin Keels, DNP, APRN, NNP-BC

GOING FROM “GOOD” TO “BEST”

So, what’s next? While lengths of stay and treatment methods have improved, the problem of NAS isn’t going away.

“While we’ve reduced the length of stay, and hospital, insurance and government policies have been put into place to reduce the number of prescription opioids ‘out there,’ we aren’t seeing a reduction in patients with NAS,” says Dr. Keels. “As a society, we have a lot more work to do.”

Dr. Reber says that the role of a children’s hospital begins before the mother is even in the delivery room. Pregnancy is often a trigger for a woman with addiction to seek treatment.

“We know that babies born to mothers on maintenance medication – such as methadone or buprenorphine – have much better outcomes and fewer symptoms than those on multiple illicit substances or drugs that are not regulated by a physician,” says Dr. Reber. “A multidisciplinary team of health care providers, social workers and community partners is needed to engage with these mothers as soon as they become pregnant so that they can get into treatment.”

This is the idea behind the Substance Abuse, Treatment, Education and Prevention Program (STEPP) clinic at The Ohio State University Wexner Medical Center. The clinic provides medication-assisted treatment, counseling, prenatal care and an opportunity for women to meet with neonatal nurses, social workers, lactation specialists, pediatricians and neonatologists such as Dr. Reber who can prepare moms for what caring for an opioid-exposed baby might require.

"A multidisciplinary team of health care providers, social workers and community partners is needed to engage with [addicted] mothers as soon as they become pregnant so that they can get into treatment." – Kris Reber, MD

ON THE HORIZON: A REVOLUTION IN NAS CARE?

Experts suggest the next step is to move NAS care out of the NICU entirely.

The NICU isn’t a quiet and restful place. Babies with NAS are already overstimulated. While efforts are underway to change the feel of the intensity of the NICU and make it more comfortable, it’s not the ideal setting for infants with NAS. But the well-baby nursery isn’t equipped to handle the special needs and extra care these babies and families require.

What Dr. McClead has in mind is something else entirely – but it will require creativity, collaboration and flexibility among insurance companies, birthing hospitals and pediatric institutions.

What if a baby with NAS could room-in with her mother? What if the mother and baby’s hospital stays were both extended so that they could stay together, receiving medical support and counseling in a low intensity setting? What if this could be done in community hospitals as well as in major metropolitan health systems? Or even in an outpatient setting?

Proofs of those concepts are popping up in a few places around the country. A team at Dartmouth published a study in 2017 outlining the medical, financial and perhaps social benefits of keeping moms and their babies with NAS together in the postpartum period.

Keeping moms and babies together can reduce NICU admissions and preserves the critical mother-child bond.

Here in central Ohio, Dr. Halpern led a successful pilot program funded by a grant from the State of Ohio that incorporated prenatal counseling and care with postnatal rooming-in and support from a highly trained nursing staff. The Mother-Infant Recovery Clinic included a weekly, half-day clinic in the Outpatient Care Center at Nationwide Children’s. There, moms-to-be received medication-assisted treatment for their addiction, prenatal care, counseling and education about parenting and caring for babies with NAS all in one appointment. In the third trimester, Dr. Halpern would meet with each mom and talk to her about what to expect during the postnatal period.

OhioHealth Grant Medical Center was the delivery hospital for the program. Hospital administrators agreed to let the moms and babies room-in together for up to 5 days – even if Medicaid didn’t fully cover it. For vaginal deliveries, the insurance coverage is typically only 48 hours after delivery.

Labor and delivery nurses, as well as postpartum nurses, were trained about how to support the new moms in a positive, non-adversarial way.

“We can’t stress enough that many of these women face challenges that many of us cannot fully understand. Many of them have experienced trauma that contributed to their substance abuse disorder. Many also have a behavioral health diagnosis, and few have strong social and socioeconomic support systems,” says Dr. Halpern. “Treating moms well in the health care setting so that they can learn skills they need to parent helps them build the confidence they need to be good moms. That, in turn, gives them the confidence they need to continue treating their own disease.”

“We went from a 50 percent admission rate to the NICU for this population to 10 percent. That’s an outstanding savings in cost and unnecessary exposures to the drugs required for weaning, and it’s an outstanding benefit to families. Preserving that mother-child bond is critical for reducing the risk of future child abuse or neglect.” – Barry Halpern, MD

By the time the pilot ended, 90 percent of babies born to mothers in the program never saw the inside of the NICU. They were treated with nonpharmacologic methods only and were discharged to home within 3 to 5 days.

“These are huge gains,” says Dr. Halpern. “We went from a 50 percent admission rate to the NICU for this population to 10 percent. That’s an outstanding savings in cost and unnecessary exposures to the drugs required for weaning, and it’s an outstanding benefit to families. Preserving that mother-child bond is critical for reducing the risk of future child abuse or neglect.”

According to Dr. Halpern, the findings of the pilot could be translated to maternity hospitals large and small, but it requires collaboration and funding. He and his team are currently working to fund the program in a sustainable way, so that it is not dependent on state grants, which have run out.

Dr. Reber suggests that this rooming-in could also be done if the baby is on pharmacologic treatment. And she points to the possible role of supportive living facilities where moms and babies could continue to get multidisciplinary support during the transition period after discharge from the hospital.

“We do a great job taking care of the moms and babies when they are in the hospital. But then we send them out into the unknown – usually without the resources they need to be successful in sobriety,” she says.

In his “free time,” Dr. Halpern meets with pregnant women at a local medication-assisted treatment clinic.

“All moms, including women with addiction, deserve the best chance for themselves and their babies,” he says. “We can and we must continue to do better for them.”